Commentary: Evidence-Informed Recommendation to Achieve Approximate Parity in the Allowed Number of Doses for Common Psychedelics

In recent years, policymakers have proposed and implemented regulatory changes promoting the deprioritization, decriminalization, or state-level legalization of one or more psychedelic substances, usually referencing data from clinical trials as reasons to support liberalizing drug control policies. As psychedelic policies continue to be drafted, personal possession limits may be considered for inclusion in those regulations. If "allowable amount" limits are to be written into law to set personal possession limits, then such amounts should be more consistently related to psychedelic doses found to be safe and efficacious in clinical trials, existing data on moderate-high doses commonly used in various naturalistic settings, and the few studies that estimate psychedelic dose equivalence based on the intensity of subjective effects. In this commentary, we provide an evidence-informed table of typical moderate-high doses for seven commonly used psychedelic substances. These estimates of comparable moderate-high doses can be used to inform "allowable amount" values for psychedelic substances. When such limits are written into legislation, the adoption of evidence-informed comparable limits akin to those presented here would be an important first step toward ensuring greater parity and consistency in drug policy, relative to limits that have little or no scientific basis.

Survey of subjective "God encounter experiences": Comparisons among naturally occurring experiences and those occasioned by the classic psychedelics psilocybin, LSD, ayahuasca, or DMT

Naturally occurring and psychedelic drug-occasioned experiences interpreted as personal encounters with God are well described but have not been systematically compared. In this study, five groups of individuals participated in an online survey with detailed questions characterizing the subjective phenomena, interpretation, and persisting changes attributed to their single most memorable God encounter experience (n = 809 Non-Drug, 1184 psilocybin, 1251 lysergic acid diethylamide (LSD), 435 ayahuasca, and 606 N,N-dimethyltryptamine (DMT)). Analyses of differences in experiences were adjusted statistically for demographic differences between groups. The Non-Drug Group was most likely to choose "God" as the best descriptor of that which was encountered while the psychedelic groups were most likely to choose "Ultimate Reality." Although there were some other differences between non-drug and the combined psychedelic group, as well as between the four psychedelic groups, the similarities among these groups were most striking. Most participants reported vivid memories of the encounter experience, which frequently involved communication with something having the attributes of being conscious, benevolent, intelligent, sacred, eternal, and all-knowing. The encounter experience fulfilled a priori criteria for being a complete mystical experience in approximately half of the participants. More than two-thirds of those who identified as atheist before the experience no longer identified as atheist afterwards. These experiences were rated as among the most personally meaningful and spiritually significant lifetime experiences, with moderate to strong persisting positive changes in life satisfaction, purpose, and meaning attributed to these experiences. Among the four groups of psychedelic users, the psilocybin and LSD groups were most similar and the ayahuasca group tended to have the highest rates of endorsing positive features and enduring consequences of the experience. Future exploration of predisposing factors and phenomenological and neural correlates of such experiences may provide new insights into religious and spiritual beliefs that have been integral to shaping human culture since time immemorial.

Psilocybin-occasioned mystical-type experience in combination with meditation and other spiritual practices produces enduring positive changes in psychological functioning and in trait measures of prosocial attitudes and behaviors

Psilocybin can occasion mystical-type experiences with participant-attributed increases in well-being. However, little research has examined enduring changes in traits. This study administered psilocybin to participants who undertook a program of meditation/spiritual practices. Healthy participants were randomized to three groups (25 each): (1) very low-dose (1 mg/70 kg on sessions 1 and 2) with moderate-level ("standard") support for spiritual-practice (LD-SS); (2) high-dose (20 and 30 mg/70 kg on sessions 1 and 2, respectively) with standard support (HD-SS); and (3) high-dose (20 and 30 mg/70kg on sessions 1 and 2, respectively) with high support for spiritual practice (HD-HS). Psilocybin was administered double-blind and instructions to participants/staff minimized expectancy confounds. Psilocybin was administered 1 and 2 months after spiritual-practice initiation. Outcomes at 6 months included rates of spiritual practice and persisting effects of psilocybin. Compared with low-dose, high-dose psilocybin produced greater acute and persisting effects. At 6 months, compared with LD-SS, both high-dose groups showed large significant positive changes on longitudinal measures of interpersonal closeness, gratitude, life meaning/purpose, forgiveness, death transcendence, daily spiritual experiences, religious faith and coping, and community observer ratings. Determinants of enduring effects were psilocybin-occasioned mystical-type experience and rates of meditation/spiritual practices. Psilocybin can occasion enduring trait-level increases in prosocial attitudes/behaviors and in healthy psychological functioning. Trial Registration ClinicalTrials.gov Identifier NCT00802282.

Survey study of challenging experiences after ingesting psilocybin mushrooms: Acute and enduring positive and negative consequences

Acute and enduring adverse effects of psilocybin have been reported anecdotally, but have not been well characterized. For this study, 1993 individuals (mean age 30 yrs; 78% male) completed an online survey about their single most psychologically difficult or challenging experience (worst "bad trip") after consuming psilocybin mushrooms. Thirty-nine percent rated it among the top five most challenging experiences of his/her lifetime. Eleven percent put self or others at risk of physical harm; factors increasing the likelihood of risk included estimated dose, duration and difficulty of the experience, and absence of physical comfort and social support. Of the respondents, 2.6% behaved in a physically aggressive or violent manner and 2.7% received medical help. Of those whose experience occurred >1 year before, 7.6% sought treatment for enduring psychological symptoms. Three cases appeared associated with onset of enduring psychotic symptoms and three cases with attempted suicide. Multiple regression analysis showed degree of difficulty was positively associated, and duration was negatively associated, with enduring increases in well-being. Difficulty of experience was positively associated with dose. Despite difficulties, 84% endorsed benefiting from the experience. The incidence of risky behavior or enduring psychological distress is extremely low when psilocybin is given in laboratory studies to screened, prepared, and supported participants.

Do Drugs Have Religious Import? A 40-Year Retrospective

Four decades ago, Huston Smith published one of the mostinfluential articles ever written on psychedelics, titled “Do Drugs HaveReligious Import?” As part of “The Oral History of PsychedelicResearch Project,” he was interviewed and invited to revisit thistopic. The interview covers his personal experiences, as well as the influences of psychedelic experiences on religious traditions andcontemplative practices. Examples of such influences that arediscussed include the ancient Vedic tradition and Eleusinianmysteries, and the contemporary Native American Church. At the sociallevel, he reflects on factors that limited the effectiveness of the psychedelic movement of the 1960s in producing significant socialchange, the state of contemporary culture, society, and drug policy,and the role of elders in society.

Abstract 271: An Electronic, Point-of-Care Cath Lab Clinical Application Provides High Validity, Completeness, and Timeliness Compared to Traditional Medical Charting

Background: Beginning in 2005, an electronic, point-of-care clinical application (CART-CL) was implemented in all 78 VA cardiac catheterization laboratories. CART-CL collects pre-procedural and procedural data in a standardized format that is recorded in the VA electronic health record. This application was created to support quality improvement, but the validity, completeness, and timeliness of these data, relative to a standard medical record are unknown.

Methods: In a random sample of 10 VA catheterization labs, we abstracted a standardized set of key data elements (based on the National Cardiovascular Data Repository mortality model) from the reports of catheterization procedures. At each site, we selected 10 procedures performed before CART-CL adoption and 10 after adoption for comparison. Notes from procedures performed before CART-CL adoption were entered directly into VISTA/CPRS, VA’s electronic health record. Validity was assessed by comparing data elements recorded in notes generated by CART-CL versus VISTA/CPRS. Completeness was assessed using a standardized list of data elements. Timeliness was defined as the percentage of catheterization reports available to the treating provider on the day of the procedure.

Results: The 200 cases selected were evenly distributed between elective and ACS indications. Of the 1690 observations abstracted from CART-CL-generated notes and analyzed for validity, 1664 (98.5%) were valid. Only 7 data elements had less than 100% validity with lowest validity found in diabetes medications (94%) and statin dose (84%). Two thousand five hundred eighty-one of 3276 (79%) data elements in CART-CL were complete, as compared with 2098 of 3323 (63.1%) data elements in CPRS charts before CART-CL implementation (p-value < 0.0001). The number of data elements analyzed for validity and completeness differed due to varying prevalence of conditions and procedures within the study population. Seventy-one percent of CART-CL catheterization reports were available to treating providers the day of the procedure, as compared with 58.0% of VISTA/CPRS catheterization notes before CART-CL adoption (p-value = 0.055). Among those reports not available on the day of the procedure, the median time-to-availability was not significantly shorter after adoption of CART-CL than before (3.0 vs. 5.0 days, p-value = 0.887).

Conclusions: CART-CL is an electronic, point-of-care clinical application that collects VA cath lab patient and procedural information in a standardized fashion. Compared to the previous method of medical charting, it has high validity, and superior completeness and timeliness. Accordingly, it can serve as an effective quality assessment tool for cath labs.

Psilocybin occasioned mystical-type experiences: immediate and persisting dose-related effects

RATIONALE

This dose-effect study extends previous observations showing that psilocybin can occasion mystical-type experiences having persisting positive effects on attitudes, mood, and behavior.

OBJECTIVES

This double-blind study evaluated psilocybin (0, 5, 10, 20, 30 mg/70 kg, p.o.) administered under supportive conditions.

METHODS

Participants were 18 adults (17 hallucinogen-naïve). Five 8-h sessions were conducted individually for each participant at 1-month intervals. Participants were randomized to receive the four active doses in either ascending or descending order (nine participants each). Placebo was scheduled quasi-randomly. During sessions, volunteers used eyeshades and were instructed to direct their attention inward. Volunteers completed questionnaires assessing effects immediately after and 1 month after each session, and at 14 months follow-up.

RESULTS

Psilocybin produced acute perceptual and subjective effects including, at 20 and/or 30 mg/70 kg, extreme anxiety/fear (39% of volunteers) and/or mystical-type experience (72% of volunteers). One month after sessions at the two highest doses, volunteers rated the psilocybin experience as having substantial personal and spiritual significance, and attributed to the experience sustained positive changes in attitudes, mood, and behavior, with the ascending dose sequence showing greater positive effects. At 14 months, ratings were undiminished and were consistent with changes rated by community observers. Both the acute and persisting effects of psilocybin were generally a monotonically increasing function of dose, with the lowest dose showing significant effects.

CONCLUSIONS

Under supportive conditions, 20 and 30 mg/70 kg psilocybin occasioned mystical-type experiences having persisting positive effects on attitudes, mood, and behavior. Implications for therapeutic trials are discussed.

Outcomes of hospitalized patients with non-acute coronary syndrome and elevated cardiac troponin level

OBJECTIVE

Cardiac troponin levels help risk-stratify patients presenting with an acute coronary syndrome. Although cardiac troponin levels may be elevated in patients presenting with non-acute coronary syndrome conditions, specific diagnoses and long-term outcomes within that cohort are unclear.

METHODS

By using the Veterans Affairs centralized databases, we identified all hospitalized patients in 2006 who had a troponin assay obtained during their initial reference hospitalization. On the basis of the diagnostic codes of the International Classification of Diseases, 9th Revision, primary diagnoses were categorized as acute coronary syndrome or non-acute coronary syndrome conditions.

RESULTS

Of a total of 21,668 patients with an elevated troponin level who were discharged from the hospital, 12,400 (57.2%) had a non-acute coronary syndrome condition. Among that cohort, the most common diagnostic category involved the cardiovascular system, and congestive heart failure (N=1661) and chronic coronary artery disease (N=1648) accounted for the major classifications. At 1 year after hospital discharge, mortality in patients with a non-acute coronary syndrome condition was 22.8% and was higher than in the acute coronary syndrome cohort (odds ratio 1.39; 95% confidence interval, 1.30-1.49). Despite the high prevalence of cardiovascular diseases in patients with a non-acute coronary syndrome diagnosis, use of cardiac imaging within 90 days of hospitalization was low compared with that in patients with acute coronary syndrome (odds ratio 0.25; 95% confidence interval, 0.23-0.27).

CONCLUSIONS

Hospitalized patients with an elevated troponin level more often have a primary diagnosis that is not an acute coronary syndrome. Their long-term survival is poor and justifies novel diagnostic or therapeutic strategy-based studies to target the highest risk subsets before hospital discharge.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System

BACKGROUND

Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining.

METHODS

We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files.

RESULTS

Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08).

CONCLUSION

Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Mystical-type experiences occasioned by psilocybin mediate the attribution of personal meaning and spiritual significance 14 months later

Psilocybin has been used for centuries for religious purposes; however, little is known scientifically about its long-term effects. We previously reported the effects of a double-blind study evaluating the psychological effects of a high psilocybin dose. This report presents the 14-month follow-up and examines the relationship of the follow-up results to data obtained at screening and on drug session days. Participants were 36 hallucinogen-naïve adults reporting regular participation in religious/ spiritual activities. Oral psilocybin (30 mg/70 kg) was administered on one of two or three sessions, with methylphenidate (40 mg/70 kg) administered on the other session(s). During sessions, volunteers were encouraged to close their eyes and direct their attention inward. At the 14-month follow-up, 58% and 67%, respectively, of volunteers rated the psilocybin-occasioned experience as being among the five most personally meaningful and among the five most spiritually significant experiences of their lives; 64% indicated that the experience increased well-being or life satisfaction; 58% met criteria for having had a 'complete' mystical experience. Correlation and regression analyses indicated a central role of the mystical experience assessed on the session day in the high ratings of personal meaning and spiritual significance at follow-up. Of the measures of personality, affect, quality of life and spirituality assessed across the study, only a scale measuring mystical experience showed a difference from screening. When administered under supportive conditions, psilocybin occasioned experiences similar to spontaneously occurring mystical experiences that, at 14-month follow-up, were considered by volunteers to be among the most personally meaningful and spiritually significant of their lives.

Psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance

RATIONALE

Although psilocybin has been used for centuries for religious purposes, little is known scientifically about its acute and persisting effects.

OBJECTIVES

This double-blind study evaluated the acute and longer-term psychological effects of a high dose of psilocybin relative to a comparison compound administered under comfortable, supportive conditions.

MATERIALS AND METHODS

The participants were hallucinogen-naïve adults reporting regular participation in religious or spiritual activities. Two or three sessions were conducted at 2-month intervals. Thirty volunteers received orally administered psilocybin (30 mg/70 kg) and methylphenidate hydrochloride (40 mg/70 kg) in counterbalanced order. To obscure the study design, six additional volunteers received methylphenidate in the first two sessions and unblinded psilocybin in a third session. The 8-h sessions were conducted individually. Volunteers were encouraged to close their eyes and direct their attention inward. Study monitors rated volunteers' behavior during sessions. Volunteers completed questionnaires assessing drug effects and mystical experience immediately after and 2 months after sessions. Community observers rated changes in the volunteer's attitudes and behavior.

RESULTS

Psilocybin produced a range of acute perceptual changes, subjective experiences, and labile moods including anxiety. Psilocybin also increased measures of mystical experience. At 2 months, the volunteers rated the psilocybin experience as having substantial personal meaning and spiritual significance and attributed to the experience sustained positive changes in attitudes and behavior consistent with changes rated by community observers.

CONCLUSIONS

When administered under supportive conditions, psilocybin occasioned experiences similar to spontaneously occurring mystical experiences. The ability to occasion such experiences prospectively will allow rigorous scientific investigations of their causes and consequences.

B-Type Natriuretic Peptide (BNP) Levels and Ethnic Disparities in Perceived Severity of Heart Failure

BACKGROUND

Previous studies have shown that in patients presenting to the emergency department (ED) with heart failure, there is a disconnect between the perceived severity of congestive heart failure (CHF) by physicians and the severity as determined by B-type natriuretic peptide (BNP) levels. Whether ethnicity plays a role in this discrepancy is unknown.

METHODS AND RESULTS

The Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) was a 10-center trial of 464 patients seen in the ED with acute dyspnea and BNP level higher than 100 pg/mL on arrival. Physicians were blinded to BNP levels. Patients were followed for 90 days after discharge. A total of 151 patients identified themselves as white (32.5%) and 294 as black (63.4%). Of these, 90% were hospitalized. African Americans were more likely to be perceived as New York Heart Association class I or II than whites (P = .01). Blacks who were discharged from the ED had higher median BNP levels than whites who were discharged (1293 vs. 533, P = .004). The median BNP of blacks who were discharged was actually higher than the median BNP of blacks who were admitted (1293 vs. 769, P = .04); the same did not hold true for whites. BNP was predictive of 90-day outcome in both blacks and whites; however, perceived severity of CHF, race, and ED disposition did not contribute to the prediction of events.

CONCLUSION

In patients presenting to the ED with heart failure, the disconnect between perceived severity of CHF and severity as determined by BNP levels is most pronounced in African Americans.

Gray zone BNP levels in heart failure patients in the emergency department: results from the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) multicenter study

OBJECTIVES

The study purpose was to examine "gray zone" B-type natriuretic peptide (BNP) levels (100-500 pg/mL) in terms of associated clinical factors, perceived severity, and outcomes in patients with established congestive heart failure (CHF).

BACKGROUND

Although gray zone BNP levels may have diagnostic ambiguity, the implications of these levels in patients with an established diagnosis of CHF have not been examined.

METHODS

REDHOT was a national prospective study in which 464 patients seen in the emergency department with dyspnea had BNP levels drawn. Entrance criteria included a BNP > 100 pg/mL; however, physicians were blinded to the actual BNP level. Patients were followed up for 90 days.

RESULTS

Thirty-three percent had gray zone BNP levels. There was no difference in perceived New York Heart Association class (P = .32) or admission rates (P = .76) between the gray zone and non-gray zone groups; 62% of patients with a gray zone BNP were identified as class III or IV CHF. Despite this perceived severity, the 90-day event rate was lower in the gray zone group (19.2% vs 32.9%, respectively, P = .002). Although patients in the gray zone had more symptoms of concomitant pulmonary disease, multivariate analysis could not demonstrate any variable that worsened the prognosis of patients with a gray zone BNP level.

CONCLUSIONS

In patients with established CHF, those with gray zone BNP levels have a better prognosis than those with non-gray zone levels despite being perceived by physicians as having New York Heart Association class III or IV CHF.

Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT). A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath

OBJECTIVES

The purpose of this study was to examine the relationships among B-type natriuretic peptide (BNP) levels within the diagnostic range, perceived congestive heart failure (CHF) severity, clinical decision making, and outcomes of the CHF patients presenting to emergency department (ED).

BACKGROUND

Since BNP correlates with the presence of CHF, disease severity, and prognosis, we hypothesized that BNP levels in the diagnostic range offer value independent of physician decision making with regard to critical outcomes in emergency medicine.

METHODS

The Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) study was a 10-center trial in which patients seen in the ED with shortness of breath were consented to have BNP levels drawn on arrival. Entrance criteria included a BNP level >100 pg/ml. Physicians were blinded to the actual BNP level and subsequent BNP measurements. Patients were followed up for 90 days after discharge.

RESULTS

Of the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be New York Heart Association (NYHA) functional class III or IV. The BNP levels did not differ significantly between patients who were discharged home from the ED and those admitted (976 vs. 766, p = 0.6). Using logistic regression analysis, an ED doctor's intention to admit or discharge a patient had no influence on 90-day outcomes, while the BNP level was a strong predictor of 90-day outcome. Of admitted patients, 11% had BNP levels <200 pg/ml (66% of which were perceived NYHA functional class III or IV). The 90-day combined event rate (CHF visits or admissions and mortality) in the group of patients admitted with BNP <200 pg/ml and >200 pg/ml was 9% and 29%, respectively (p = 0.006).

CONCLUSIONS

In patients presenting to the ED with heart failure, there is a disconnect between the perceived severity of CHF by ED physicians and severity as determined by BNP levels. The BNP levels can predict future outcomes and thus may aid physicians in making triage decisions about whether to admit or discharge patients. Emerging clinical data will help further refine biomarker-guided outpatient therapeutic and monitoring strategies involving BNP.

Short course of omeprazole: a better first diagnostic approach to noncardiac chest pain than endoscopy, manometry, or 24-hour esophageal pH monitoring

Noncardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP.

GOALS

To test the efficacy of a potent acid-suppressing agent as a diagnostic test in the evaluation of NCCP and to compare it with three commonly used tests.

STUDY

Eighteen men and 24 women, aged 22 to 77 years, who presented with recurrent chest pain complaints of a noncardiac etiology, as determined by rest/stress perfusion imaging with technetium Tc99m sestamibi (MIBI), were enrolled in a prospective, double-blinded, placebo-controlled, crossover trial using high-dose omeprazole. Thirty-seven patients completed both arms of the trial. Findings were compared with those of endoscopy, manometry, and ambulatory 24-hour two-channel esophageal pH monitoring. All patients underwent initial diagnostic upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were then randomly assigned to either placebo or omeprazole (40 mg/d orally twice daily) for 14 days, washed out for 21 days, and then crossed over. Patient's symptoms were determined using a Visual Analogue Scale to measure the severity of chest pain before and after each period.

RESULTS

Seventy-one percent of patients in the omeprazole arm reported improved chest pain, whereas only 18% in the placebo arm did. Abnormal results on manometry (20%), 24-hour pH monitoring (42%), or endoscopy with visual evidence of esophagitis (26%) were found less frequently. Combination of the three tests did not significantly increase their usefulness. In NCCP patients with GERD, as defined by positive results on a 24-hour pH test or presence of esophagitis on endoscopy, omeprazole treatment led to a response in 95% of patients, whereas 90% of GERD-positive patients treated with placebo did not respond. Of NCCP patients determined to be GERD negative, 39% responded to omeprazole.

CONCLUSIONS

Omeprazole as a first diagnostic tool in the evaluation of MIBI-negative NCCP is sensitive and specific for determining the cause of NCCP. Endoscopy, manometry, and 24-hour pH monitoring were not only less sensitive in diagnosing NCCP, but they were significantly more expensive.

A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease. Antithrombotic Therapy Consortium Investigators

BACKGROUND

Therapy with intravenous unfractionated heparin improves clinical outcome in patients with active thromboembolic disease, but achieving and maintaining a therapeutic level of anticoagulation remains a major challenge for clinicians.

METHODS

A total of 113 patients requiring heparin for at least 48 hours were randomly assigned at 7 medical centers to either weight-adjusted or non-weight-adjusted dose titration. They were separately assigned to either laboratory-based or point-of-care (bedside) coagulation monitoring.

RESULTS

Weight-adjusted heparin dosing yielded a higher mean activated partial thromboplastin time (aPTT) value 6 hours after treatment initiation than non-weight-adjusted dosing (99.9 vs 78.8 seconds; P =.002) and reduced the time required to exceed a minimum threshold (aPTT >45 seconds) of anticoagulation (10.5 vs 8.6 hours; P =.002). Point-of-care coagulation monitoring significantly reduced the time from blood sample acquisition to a heparin infusion adjustment (0.4 vs 1.6 hours; P <.0001) and to reach the therapeutic aPTT range (51 to 80 seconds) (16.1 vs 19.4 hours; P =.24) compared with laboratory monitoring. Although a majority of patients participating in the study surpassed the minimum threshold of anticoagulation within the first 12 hours and reached the target aPTT within 24 hours, maintaining the aPTT within the therapeutic range was relatively uncommon (on average 30% of the overall study period) and did not differ between treatment or monitoring strategies.

CONCLUSIONS

Weight-adjusted heparin dosing according to a standardized titration nomogram combined with point-of-care coagulation monitoring using the BMC Coaguchek Plus System represents an effective and widely generalizable strategy for managing patients with thromboembolic disease that fosters the rapid achievement of a desired range of anticoagulation. Additional work is needed, however, to improve on existing patient-specific strategies that can more effectively sustain a therapeutic state of anticoagulation.

Peroxide induces vasoconstriction in the human placenta by stimulating thromboxane

OBJECTIVE

Placental lipid peroxides and thromboxane are abnormally increased in preeclampsia. Thromboxane is a potent vasoconstrictor of the placental vasculature. Peroxides stimulate cyclooxygenase (prostaglandin H synthase), and thereby could increase thromboxane, to cause vasoconstriction in the placenta. This study was performed to test the hypothesis that peroxides would produce vasoconstriction in the human placenta by stimulating thromboxane production.

STUDY DESIGN

Isolated human placental cotyledons were perfused for 20-minute intervals with 100 mumol/L t-butyl hydroperoxide alone, and during and after perfusion with low-dose aspirin (5 x 10(-5) mol/L) (n = 6) or the thromboxane receptor blocker SQ 29,548 (n = 2). Krebs-Ringer-bicarbonate buffer gassed with 95% oxygen and 5% carbon dioxide was used for the perfusion buffer. Perfusion pressure was monitored continuously, and effluent flow rates were measured during each experimental treatment. Maternal and fetal effluent samples were analyzed for thromboxane B2 and 6-keto-prostaglandin F1 alpha.

RESULTS

Compared with control Krebs-Ringer-bicarbonate buffer perfusion, peroxide perfusion significantly increased (p < 0.05) vascular resistance (14 +/- 2 vs 25 +/- 3 mm Hg.min/ml, mean +/- SE, respectively), thromboxane B2 secretion (fetal 0.20 +/- 0.04 vs 1.65 +/- 0.26 ng/min, maternal 4.8 +/- 1.5 vs 8.1 +/- 2.1 ng/min) and 6-keto-prostaglandin F1 alpha secretion (fetal 21 +/- 5 vs 60 +/- 1.8 pg/min, maternal nondetectable). Peroxide perfusion increased the thromboxane B2/6-keto-prostaglandin F1 alpha ratio threefold on the fetal side. Subsequent perfusion with aspirin significantly blocked the peroxide-induced vasoconstriction (13 +/- 1 mm Hg.min/ml during aspirin + peroxide) and the peroxide-induced increase in the secretion of thromboxane B2 (fetal 0.52 +/- 0.12 ng/min, maternal 2.0 +/- 0.3 ng/min) and 6-keto-prostaglandin F1 alpha (fetal 30 +/- 8 pg/min). After perfusion with aspirin the thromboxane B2/6-keto-prostaglandin F1 alpha ratio declined. When the thromboxane receptor blocker was used instead of aspirin, maternal and fetal secretion rates of thromboxane were still significantly increased by peroxide perfusion, but there was no change in perfusion pressure or vascular resistance.

CONCLUSIONS

(1) Peroxide induces placental vasoconstriction coincident with increased secretion of thromboxane; (2) low-dose aspirin blocks both increased thromboxane secretion and vasoconstriction, whereas a thromboxane receptor antagonist allows increased thromboxane secretion but prevents peroxide induced vasoconstriction; (3) therefore, peroxide induces vasoconstriction by stimulating thromboxane synthesis.

Inhibition of highly purified mammalian phospholipases A2 by non-steroidal anti-inflammatory agents. Modulation by calcium ions

Highly purified Ca2+-dependent phospholipases A2 that were isolated from human platelets, rabbit alveolar macrophages and peritoneal polymorphonuclear leucocytes and were active in the neutral-to-alkaline pH range were inhibited 50% by 75 microM-indomethacin in the presence of 5.0 mM added Ca2+. Sodium meclofenamate and sodium flufenamate were also inhibitory; the sensitivity to inhibition was a function of Ca2+ concentration. The dose for 50% inhibition (ID50) with meclofenamate was 0.4 mM in the presence of 2.5 mM added Ca2+, but 50nM in the presence of 0.5 mM added Ca2+. Thus, inhibition of phospholipase A2 activity by non-steroidal anti-inflammatory agents via Ca2+ antagonism may significantly contribute to the mechanism of drug action.

Arteriosclerotic coronary arterial aneurysms in a 49-year-old man with crescendo angina: family history, natural course and prevalence

In a 49-year-old man with crescendo angina, elevated serum cholesterol level and an old posterior myocardial infarction, selective coronary arteriography showed multiple arteriosclerotic aneurysms of the right coronary artery associated with extensive and severe arteriosclerotic disease of the left coronary artery. The patient's mother and brother have both died of a myocardial infarction. Another brother suffers from angina and has documented arteriosclerotic coronary artery disease. Two sisters suffer from angina as well. The possibility of embolization of distal vessels from a friable clot of the aneurysms as a cause of the patient's infarction is discussed. To the best of our knowledge, this is the tenth patient with nonfistulous arteriosclerotic coronary artery aneurysm diagnosed and documented angiographically ante mortem. Including the present case and reviewing the literature, the prevalence of this condition among nonfistulous coronary aneurysms diagnosed ante mortem is 35 per cent and henceforth cannot be regarded as an incidental autopsy finding in cardiac asymptomatic patients.

Rotational skin flaps to cover wound defect in groin

A technique of a lower relaxing incision and use of a rotational skin flap from the anterolateral thigh to close an extensive defect in the inguinal area is described. Its use is especially applicable for palliation in patients with large fungating metastases in the inguinal region.

[Coronary angiography in the pre-infarct syndrome (author's transl)]

During the first ten month of the past year (1974) we did 310 selective coronary arteriographies by the Sones technique at the Department of Cardiology of the Medical Clinic Würzburg. The incidence of complications in this comparatively small group was 0%. In seven cases we did an emergency coronary arteriography. Six of these patients were transferred immediately after examination to the Department of cardiac Surgery of the University of Erlangen for emergency aortocoronary vein bypass. One of these patients died within the next 6 hours postoperatively. Five patients in this group are in good condition. Three patients had a double aorto-coronary vein bypass.

[A new method of transseptal levocardiography]

Perforations of the left atrial or ventricular wall and extravasations of contrast medium during transseptal left heart catheterization or angiocardiography can be eliminated by replacing the routinely used transseptal catheters with Pigtail-catheters. With 2.8% minor complications without sequelas in 181 successful studies, transseptal angiocardiography of the left heart through Pigtail-catheters is not only less hazardous than injections through the transseptal catheters employed up to now, but bears even less risk than direct retrograde injection into the left ventricle. To show the left atrial cavity and the mitral valve, transseptal left atrial injection is the method of choice. For quantitative angiocardiography to evaluate left ventricular function, transseptal angiocardiography with injection into the left atrium is superior to retrograde direct ventriculography in our experience, as ventricular ectopic beats were absent and supraventricular ectopic beats as rare as 5% of the cases, local disturbances of wall motion during injection could be avoided and 1 or 2 more cycles could be evaluated before the depressant effect of contrast medium started.

[The effect of intravenous infusion of glucagon on the contractility of the left ventricular myocardum in man (author's transl)]

In the cases of 10 cardially healthy humans and 5 patients with heart disease, the left ventricular pressure as well as different parameters of contractility - deduced from the pressure curve and its first derivative - were determined by a catheter-tip manometer (Statham SF - 1). In particular the following values were concerned: dP/dtmax,-dP/dtmaxDP, the maximal calculated shortening velocity of the contractile elements according to the 2-component heart muscle model (VCEmaxTP) as well as with the Maxwell model (VCEmaxDP) and finally the (extrapolated) maximum shortening velocity (Vmax) under a fictive zero load. The examinations were carried out before and during a 10-minute infusion of 60 mg/kg glucagon and 10 minutes after completing the infusion. Besides glucagon also digoxin, etilefrin-HCl-1) and orciprenaline-2) were delivered and the same measurements were performed as with glucagon. A definite statement about the priority of any one of the named indices of contractility is rendered more difficult, because the enddiastolic pressure does not change substantially with glucagon. An unequivocal demarcation of frequency and pressure effects and of inotropic mechanisms as just as impossible, because, with the exception of VmaxDP, all parameters react quantitatively and qualitatively in an equal manner. On the basis of VmaxTP the result of glucagon is only a slight increase in the myocardial contractile capability, which would hardley suffice for the treatment of patients, who do not respond to digitalis. The decline of VmaxDP under glucagon cannot be explained. Under digitalis, etilefrin and orciprenaline, a similar dissociation of values for the maximum shortening velocity according to the 2- or 3-component-model of the heart muscle cannot be demonstrated.

[Myocardial metabolism under intravenous infusion of glucagon (author's transl)]

In 7 healthy-hearted probands the arterial-coronary-venous oxygen difference for glucose, K+, lactate, pO2, pCO2 and pH during a glucagon infusion was determined and compared with the values before and 10 minutes after infusion. Contradictory to the unchanged myocardial lactate extraction and the positively or negatively influenced K+-uptake recorded in the literature, in this contingent there was a statistically significant myocardial lactate production and an unchanged potassium uptake. The respiratory quotient of the heart increased. These changes are regarded as the result of a direct hormonal influence on the myocardial metabolism and have nothing to do with the change of an aerobic into an anaerobic metabolic state.